The Japanese breast cancer society clinical practice guidelines for radiation treatment of breast cancer, 2022 edition.

The Breast Cancer Clinical Practice Guidelines, organized by the Japanese Breast Cancer Society (JBCS), were published in 2022. We present the English version of the Radiation Therapy (RT) section of the guidelines. The JBCS formed a task force to update the 2018 version of the JBCS Clinical Practice Guidelines. The Background Questions (BQs) contain the standard treatments for breast cancer in clinical practice, whereas the Clinical Questions (CQs) address daily clinical questions that remain controversial. Future Research Questions (FRQs) explore the subjects that are considered important issues, despite there being insufficient data for inclusion as CQs. The task force selected the 12 BQs, 8 CQs, and 6 FRQs for the RT section. For each CQ, systematic literature reviews and meta-analyses were conducted according to the Minds Manual for Guideline Development 2020, version 3.0. The recommendations, strength of recommendation, and strength of evidence for each CQ were determined based on systematic reviews and meta-analyses, and finalized by voting at the recommendation decision meeting.

Sister Mary Joseph's Nodule From Renal Cell Carcinoma: A Case Report.

Sister Mary Joseph's nodules (SMJNs) are umbilical skin metastases of various abdominopelvic malignancies, and they rarely originate from renal cell carcinomas. Radiotherapy is typically used to treat the nodules as a palliative intention. We report a rare case of SMJN that originated from clear cell renal cell carcinoma, which was treated with external beam radiation therapy (EBRT) and interstitial brachytherapy (ISBT). A 74-year-old male patient with a history of left renal cell carcinoma developed an umbilical nodule which was diagnosed as SMJN. The patient underwent EBRT (30 Gy in 10 fractions) and ISBT (12 Gy in two fractions), leading the nodule to complete resolution. This case report might support that radiotherapy, including ISBT, is effective for the treatment of SMJN from renal cell carcinoma.

Comparison of thoracic and abdominal deep inspiration breath holds in whole-breast irradiation for patients with left-sided breast cancer.

BACKGROUND: The deep inspiration breath hold (DIBH) technique is effective for heart dose reduction in patients with left-sided breast cancer. In deep breathing, some women breathe in thoracic respiration; and others, in abdominal respiration. This study evaluated differences in dose reduction in organs at risk (OAR) and reproducibilities of the target and OAR between thoracic DIBH (T-DIBH) and abdominal DIBH (A-DIBH). METHODS: Fourteen patients with left-sided breast cancer who had planned to receive whole-breast irradiation were included. Computed tomography (CT) was performed in free breathing (FB), T-DIBH, and A-DIBH, and the dosimetric indexes of the target and OAR for three treatment plans were compared. In T-DIBH and A-DIBH, two series CTs were taken in each breathing method and the displacements of the target and heart were calculated. RESULTS: The averaged mean heart doses (MHDs) were 1.5 Gy and 1.6 Gy in T-DIBH and A-DIBH, respectively, significantly lower than 2.7 Gy in FB (p < 0.001 for both breathing methods). Between T-DIBH and A-DIBH, no significant difference in MHD was found (p = 0.95); however, the percentage increase in lung volume positively moderately correlated with the reduction in MHD (R = 0.68). The three-dimensional target displacements were 2.3 mm in T-DIBH and 2.0 mm in A-DIBH (p = 0.64). The three-dimensional heart displacements were 1.7 mm in T-DIBH and 1.8 mm in A-DIBH (p = 0.85). CONCLUSION: The present study demonstrates that the MHD and reproducibility did not differ between T-DIBH and A-DIBH. However, the superior breathing method for increasing lung volume should be determined for each patient.

Histological diagnostic criterion for chronic endometritis based on the clinical outcome.

BACKGROUND: The diagnostic criteria of chronic endometritis remain controversial in the treatment for infertile patients. METHODS: A prospective observational study was conducted in a single university from June 2014 to September 2017. Patients who underwent single frozen-thawed blastocyst transfer with a hormone replacement cycle after histological examination for the presence of chronic endometritis were enrolled. Four criteria were used to define chronic endometritis according to the number of plasma cells in the same group of patients: 1 or more (≥ 1) plasma cells, 2 or more (≥ 2), 3 or more (≥ 3), or 5 or more (≥ 5) in 10 high-power fields. Pregnancy rates, live birth rates, and miscarriage rates of the non-chronic endometritis and the chronic endometritis groups defined with each criterion were calculated. A logistic regression analysis was performed for live births using eight explanatory variables (seven infertility factors and chronic endometritis). A receiver operating characteristic curve was drawn and the optimal cut-off value was calculated. RESULTS: A total of 69 patients were registered and 53 patients were finally analyzed after exclusion. When the diagnostic criterion was designated as the presence of ≥ 1 plasma cell in the endometrial stroma per 10 high-power fields, the pregnancy rate, live birth rate, and miscarriage rate were 63.0% vs. 30.8%, 51.9% vs. 7.7%, and 17.7% vs. 75% in the non-chronic and chronic endometritis groups, respectively. This criterion resulted in the highest pregnancy and live birth rates among the non-chronic endometritis and the smallest P values for the pregnancy rates, live birth rates, and miscarriage rates between the non-chronic and chronic endometritis groups. In the logistic regression analysis, chronic endometritis was an explanatory variable negatively affecting the objective variable of live birth only when chronic endometritis was diagnosed with ≥ 1 or ≥ 2 plasma cells per 10 high-power fields. The optimal cut-off value was obtained when one or more plasma cells were found in 10 high-power fields (sensitivity 87.5%, specificity 64.9%). CONCLUSIONS: Chronic endometritis should be diagnosed as the presence of ≥ 1 plasma cells in 10 high-power fields. According to this diagnostic criterion, chronic endometritis adversely affected the pregnancy rate and the live birth rate.

Laparoscopic-Assisted Hysteroscopic Surgery for Endometrial Tumors Arising after Pelvic Radiation Therapy.

Uterine tumors detected after pelvic radiation therapy are rare. We report a case in which an endometrial tumor developed after pelvic radiation therapy for cervical cancer. The patient was a 70-year-old female with a history of pelvic radiotherapy for locally advanced cervical cancer. After 12 months of radiation therapy, magnetic resonance imaging showed tumors in the uterine cavity, and positron emission tomography-computed tomography showed no tumors, except uterine tumors. Since radiation therapy-induced cervical stenosis was conducted, endometrial examination could not be performed without anesthesia. As these tumors were detected after radiation therapy for uterine cancer, malignancy was considered. A laparoscopic-assisted transcervical hysteroscopic resection was performed for the diagnosis and treatment of uterine tumors after radiation therapy. This operative method was useful and enabled us to perform complete resection, observe the abdominal cavity, prepare for the possibility of secondary hysterectomy, and improve safety.

Chromosome analysis of blastocysts derived from single pronuclear zygotes by array CGH and clinical outcomes by the transfer of single pronuclear zygotes.

PURPOSE: This study aimed to explore the aneuploidy of blastocysts derived from single pronuclear (1PN) zygotes, almost 75% of which were regarded as diploid, using array CGH and examine the pregnancy outcomes. METHODS: Embryonic aneuploidy screening of sixteen embryos from 1PN zygotes and sixteen embryos from 2PN zygotes was performed using array CGH in study 1. In addition, the reproductive outcome of 1761 single blastocysts, after untested frozen-thawed blastocyst transfer in IVF/ICSI patients, was retrospectively analyzed and compared between the 1PN and 2PN groups in study 2. RESULTS: The aneuploidy rates were 30.8% (4/13) in 1PN IVF, 33.3% (1/3) in 1PN ICSI, 46.2% (6/13) in 2PN IVF, and 100% (3/3) in 2PN ICSI. The 1PN group achieved clinical pregnancy in 25.0% (7/28) of IVF and 30.0% (3/10) of ICSI, whereas these rates in the 2PN control group were 44.6% (557/1250) of IVF and 37.4% (177/473) of ICSI. No miscarriage occurred in the pregnancies from 1PN zygotes, whereas the rates of miscarriage in the 2PN control group were 22.6% (126/557) in IVF and 22.2% (39/176) in ICSI. The delivery rate was similar in all groups. Ten deliveries in the 1PN group showed no newborn malformation. CONCLUSION: Within the limits of the small sample size, our results suggest that the aneuploidy and delivery rates of the blastocysts derived from 1PN zygotes are the same as those derived from 2PN zygotes. Blastocysts derived from 1PN zygotes may be used clinically and could increase the chance of pregnancy.

The impact of age on the risk of ipsilateral breast tumor recurrence after breast-conserving therapy in breast cancer patients with a > 5 mm margin treated without boost irradiation.

BACKGROUND: The boost irradiation to the tumor bed following whole-breast irradiation (WBI) reduced the risk of ipsilateral breast tumor recurrence (IBTR). However, in Japan, almost all patients with a margin ≤5 mm receive boost irradiation to the tumor bed, but the decision to perform boost irradiation for those with a margin > 5 mm is dependent on the institution. Thus, institutional guidelines on utilizing boost irradiation for patients aged ≤40 or ≤ 50 years vary. We investigated the IBTR rate to assess the appropriate age for boost irradiation to the tumor bed with a margin > 5 mm. METHODS: From January 1993 to December 2010, 419 patients with early-stage breast cancer and negative margins (> 5 mm) after breast-conserving surgery received WBI without boost irradiation. The Gray test was used to compare the cumulative incidence of IBTR among patients aged ≤40, 41-50, and ≥ 51 years. Hazard ratios were estimated using the Fine and Gray models. Furthermore, as a subgroup analysis, we investigated whether IBTR depended on the use of systemic therapy, such as anthracycline or taxane regimens. RESULTS: The median follow-up time was 9.3 years. In multivariate analysis, only age predicted IBTR (p = 0.047). The 10-year IBTR rate was 15.7% in patients aged ≤40, 3.8% in those aged 41-50, and 2.0% in patients aged ≥51 years. The difference between patients aged ≤40 and 41-50 years was statistically significant (p = 0.045), whereas the difference between patients aged 41-50 and ≥ 51 years was not significant (p = 0.21). CONCLUSIONS: In our institutional surgical setting, when boost irradiation is performed only for patients with a margin ≤5 mm, the IBTR rate after WBI without boost irradiation was significantly higher in patients aged ≤40 years, suggesting that boost irradiation should be used for patients in this age group.

Review: Chronic endometritis and its effect on reproduction.

AIM: Chronic endometritis (CE) is a disease of continuous and subtle inflammation characterized by the infiltration of plasma cells in the endometrial stromal area. Although the clinical significance of CE has been thought in clinical practice for a long time because it is either asymptomatic or presents with subtle symptoms, recent studies have shown the potential adverse effects of CE on fertility. In the present review, we focus on the concept, diagnosis, etiology, pathophysiology, diagnosis, impact on reproduction and treatment for it to understand CE. METHODS: The published articles were reviewed. RESULTS: The prevalence of CE has been found to be 2.8-56.8% in infertile women, 14-67.5% in women with recurrent implantation failure (RIF), and 9.3-67.6% in women with recurrent pregnancy loss. Microorganisms are thought to be a main cause of CE, since antibiotic treatment has been reported to be an effective therapy for CE. Common bacteria are frequently detected in the uterine cavity of CE patients by microbial culture. In CE endometrium, the prevalence of immune cells and decidualization has been reported to be modified, and these modifications are thought to adversely affect fertility. The gold standard for the diagnosis of CE is the histological detection of plasma cells in the stromal area of the endometrium in endometrial specimens, although universally accepted criteria for the diagnosis of CE have not been determined. The treatment currently thought to be most effective for the recovery of fertility in CE is administration of oral antibiotics. Patients whose CE has been cured have been reported to have a higher ongoing pregnancy rate, clinical pregnancy rate, and implantation rate compared with patients with persistent CE. CONCLUSION: CE greatly affects implantation and impairs fertility. Antibiotic administration is an effective therapeutic option. Pregnancy rate in in vitro fertilization is improved when CE is cured by antibiotic.

Propensity Score Analysis of Radical Hysterectomy Versus Definitive Chemoradiation for FIGO Stage IIB Cervical Cancer.

OBJECTIVE: The aim of this study was to compare the outcomes and toxicities of radical hysterectomy (RH) and definitive chemoradiation (CRT) for International Federation of Gynecology and Obstetrics (FIGO) stage IIB cervical cancer. MATERIALS AND METHODS: A retrospective analysis was performed on FIGO stage IIB patients who underwent RH with adjuvant radiotherapy (surgery group) or intended to receive CRT (CRT group). The distributions of disease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan-Meier method. Propensity score matching (PSM) was performed for the 2 groups based on age, tumor diameter, histological type, and pelvic node metastasis in pretreatment imaging tests. RESULTS: Median follow-up times were 58 months in the surgery group (n = 75) and 55 months in the CRT group (n = 65). Propensity score matching identified 37 patients with similar characteristics from each group. Significant differences were observed in the ratio of the chemotherapy combination between the surgery and CRT groups before (47% vs 98%) and after PSM (51% vs 100%). Five-year DFS rates were slightly higher in the surgery group than in the CRT group before PSM (69% vs 58%, P = 0.30) but were similar after PSM (76% vs 82%, P = 0.36). Five-year OS rates were similar between the surgery and CRT groups before (70% vs 75%, P = 0.59) and after PSM (78% vs 77%, P = 0.97). The results of multivariate analyses also showed that neither DFS nor OS was associated with the treatment modalities regardless of PSM. The incidence of late toxicities grade 2 or greater was similar between the surgery and CRT groups before (17% vs 23%, P = 0.31) and after PSM (19% vs 24%, P = 0.78). CONCLUSIONS: The results of this study suggest that RH with adjuvant radiotherapy and definitive CRT are equivalent treatment options for patients with FIGO stage IIB cancer. However, prospective larger studies are needed to confirm this.

Dosimetric advantages afforded by a new irradiation technique, Dynamic WaveArc, used for accelerated partial breast irradiation.

PURPOSE: To identify dosimetric advantages of the novel Dynamic WaveArc (DWA) technique for accelerated partial breast irradiation (APBI), compared with non-coplanar three-dimensional conformal radiotherapy (nc3D-CRT) and coplanar tangential volumetric modulated arc therapy (tVMAT) with dual arcs of 45-65°. METHODS: Vero4DRT enables DWA by continuous gantry rotation and O-ring skewing with movement of the multi-leaf collimator. We compared the dose distributions of DWA, nc3D-CRT and tVMAT in 24 consecutive left-sided breast cancer patients treated with APBI (38.5 Gy in 10 fractions). The average doses and volumes to the planning target volume (PTV) and organs at risk, especially heart and left anterior descending artery (LAD) were compared among DWA, nc3D-CRT and tVMAT. RESULTS: The doses and volumes to the PTVs did not differ significantly among the three plans. For the DWA plans, the mean dose to the heart was 0.2 ±â€¯0.1 Gy, less than those of the nc3D-CRT and tVMAT plans. The D2% values of the planning organ at risk volume of the LAD were 9.3 ±â€¯10.9%, 28.2 ±â€¯31.9% and 20.3 ±â€¯25.7% for DWA, nc3D-CRT and tVMAT, respectively. The V20Gy and V10Gy of the ipsilateral lung for the DWA plans were also significantly lower. CONCLUSIONS: DWA allowed to find a better compromise for OAR which overlapped with the PTV. Use of the DWA for APBI improved the dose distributions compared with those of nc3D-CRT and tVMAT.

Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome.

AIM: Cesarean scar syndrome (CSS) is characterized by increased risk of postmenstrual abnormal uterine bleeding, dysmenorrhea, and infertility, due to a post-cesarean scar defect known as an isthmocele. This study aimed to assess the impact of hysteroscopic surgery on isthmocele associated with CSS. METHODS: Eighteen patients with CSS were enrolled. Surgical methods included resection of the inferior edge and superficial cauterization of the isthmocele via hysteroscopic surgery. We evaluated the residual myometrial thickness and isthmocele volume using magnetic resonance imaging, before and after hysteroscopic surgery. RESULTS: All patients underwent surgery without any complications. The residual myometrium was thicker after hysteroscopic surgery (median: 2.1 mm and 4.2 mm, before and after surgery, respectively; P = 0.0001). Isthmocele volume was significantly reduced after hysteroscopic surgery (median: 494.9 mm3 and 282.8 mm3 , before and after surgery, respectively; P = 0.0016). CONCLUSION: This study demonstrated that hysteroscopic surgery is effective in increasing the residual myometrial thickness and reducing the size of isthmocele.

Granulocyte-colony-stimulating factor-producing metaplastic carcinoma of the breast with significant elevation of serum interleukin-17 and vascular endothelial growth factor levels.

Granulocyte-colony-stimulating factor (G-CSF) production in carcinomas is associated with a very aggressive phenotype. Interleukin (IL)-17 secreted from tumor-infiltrating lymphocytes induces the production of G-CSF and vascular endothelial growth factor (VEGF) in cancer tissue. We present a case of a G-CSF-producing metaplastic breast carcinoma (MpBC) accompanied by systemic elevation of IL-17 and VEGF levels. A 56-year-old woman presented with a rapidly growing tumor measuring > 10 cm in her left breast. Core needle biopsy confirmed the diagnosis as MpBC with triple-negative features. Diffuse fluorodeoxyglucose uptake in the long bones and marked leukocytosis suggested that the G-CSF was produced by the primary tumor, which showed upregulated G-CSF mRNA and protein levels. Multiplex cytokine assessment identified increased serum IL-17, VEGF, and G-CSF levels. After radical mastectomy and skin grafting, the leukocyte count and serum G-CSF, IL-17, and VEGF levels were normalized. She underwent postmastectomy radiotherapy (50 Gy/25 Fr) and adjuvant chemotherapy (90 mg/m2 of epirubicin and 600 mg/m2 of cyclophosphamide followed by 80 mg/m2 of paclitaxel) and is alive without recurrence. This is the first in vivo observation that describes the systemic elevation of IL-17 and VEGF levels with concomitant G-CSF production. Further research is warranted to study the IL-17/G-CSF/VEGF axis as a potential therapeutic target for this aggressive type of breast cancer.

Three-dimensional intrafractional internal target motions in accelerated partial breast irradiation using three-dimensional conformal external beam radiotherapy.

PURPOSE: We evaluated three-dimensional intrafractional target motion, divided into respiratory-induced motion and baseline drift, in accelerated partial breast irradiation (APBI). METHODS: Paired fluoroscopic images were acquired simultaneously using orthogonal kV X-ray imaging systems at pre- and post-treatment for 23 patients who underwent APBI with external beam radiotherapy. The internal target motion was calculated from the surgical clips placed around the tumour cavity. RESULTS: The peak-to-peak respiratory-induced motions ranged from 0.6 to 1.5mm in all directions. A systematic baseline drift of 1.5mm towards the posterior direction and a random baseline drift of 0.3mm in the lateral-medial and cranial-caudal directions were observed. The baseline for an outer tumour cavity drifted towards the lateral and posterior directions, and that for an upper tumour cavity drifted towards the cranial direction. Moderate correlations were observed between the posterior baseline drift and the patients' physical characteristics. The posterior margin for intrafractional uncertainties was larger than 5mm in patients with greater fat thickness due to the baseline drift. CONCLUSIONS: The magnitude of the intrafractional motion was not uniform according to the direction, patients' physical characteristics, or tumour cavity location due to the baseline drift. Therefore, the intrafractional systematic movement should be properly managed.

Chronic endometritis modifies decidualization in human endometrial stromal cells.

BACKGROUND: Chronic endometritis (CE) is a continuous inflammation of uterine endometrium, and it is usually symptomless. As CE has been thought not to affect the reproductive status and general health of affected women, its significance has not been explored. However, recent studies have shown that CE is related with repeated implantation failures after in vitro fertilization-embryo transfer, unexplained infertility, and recurrent miscarriages. As decidua differentiates to support the implantation process and maintains the pregnancy, we hypothesized that CE may influence the process of decidualization. METHODS: Seventeen patients were employed in the experiment involving culture of endometrial stromal cells (ESCs). After obtaining endometrial samples, ESCs were harvested and cultured for 13 days. The concentrations in culture media and the protein expressions in ESCs of prolactin (PRL) and insulin-like growth factor binding protein-1 (IGFBP-1), two well known decidualization markers used in a large number of in vitro models, were analyzed by ELISA and Western blotting, respectively, and the cell numbers were also counted. The mRNA levels of PRL and IGFBP-1 were tested by quantitative real time polymerase chain reaction (RT-PCR). Since sex hormone induce proliferation and differentiation to decidua via binding to the sex hormone receptors (ERα, ERß, PRA, and PRB), their expression was assessed in another 17 patients' paraffin-embedded endometrial tissue specimens by immunohistochemistry and semi-quantified by H-score. RESULTS: Increased cell numbers and reduced secretion of PRL and IGFBP-1 were detected by ELISA in the ESCs of CE patients after culture for 13 days compared with non-CE patients. The decreased protein expression of IGFBP-1 in ESCs of CE patients was detected by Western blotting. The decreased expression of PRL mRNA and IGFBP-1 mRNA were detected by RT-PCR. Increased expressions of ERα, ERß, PRA, and PRB were observed in the stromal cells of CE patients in comparison to non-CE patients, whereas increased expressions of ERα and ERß were detected in the glandular cells of CE. CONCLUSION: Our data suggests that CE modifies decidualization of human ESC through untuning the function of sex steroid hormone receptor.

Regional recurrence in breast cancer patients with one to three positive axillary lymph nodes treated with breast-conserving surgery and whole breast irradiation.

Radiotherapy with breast-conserving therapy plays a crucial role in the treatment of early breast cancer. However, optimal radiotherapy targets have been controversial. We therefore evaluated regional recurrence in breast cancer patients with one to three positive lymph nodes (LNs) treated with breast-conserving surgery (BCS) followed by whole-breast irradiation (WBI). From 1993 to 2010, 121 breast cancer patients with one to three positive LNs who underwent BCS followed by WBI were analyzed. All patients underwent radiotherapy with two tangential fields to the whole breast. To evaluate the radiation dose to the axillary LNs, we contoured axillary LNs area and evaluated the dose-volumetric parameters. The median follow-up time was 112.4 months (range, 15.6-248.1 months). The 5-year overall survival and disease-free survival rates were 95.6% and 86.6%, respectively. The 5-year regional recurrence-free rate (RRFR) was 97.4%. During follow-up, six patients had regional recurrence. The pathological T stage was the factor best associated with the 5-year RRFR using the log-rank test, with 100.0% in the pT1 cohort versus 94.7% in the pT2-4 cohort (P < 0.01). The radiation dose to the axillary LNs did not contribute to the RRFR. In conclusion, while the pathological T stage was the prognostic factor best associated with regional recurrence, few regional recurrences were observed in early breast cancer patients with one to three LNs treated with BCS followed by WBI. Unintentional radiation doses to the axillary LNs using standard WBI were not related to the RRFR after axillary dissection.

Dosimetric evaluation of the Acuros XB algorithm for a 4 MV photon beam in head and neck intensity-modulated radiation therapy.

In this study, we assessed the differences in the dose distribution of a 4 MV photon beam among different calculation algorithms: the Acuros XB (AXB) algorithm, the analytic anisotropic algorithm (AAA), and the pencil beam convolution (PBC) algorithm (ver. 11.0.31), in phantoms and in clinical intensity-modulated radiation therapy (IMRT) plans. Homogeneous and heterogeneous, including middle-, low-, and high-density, phantoms were combined to assess the percentage depth dose and lateral dose profiles among AXB, AAA, and PBC. For the phantom containing the low-density area, AXB was in agreement with measurement within 0.5%, while the greatest differences between the AAA and PBC calculations and measurement were 2.7% and 3.6%, respectively. AXB showed agreement with measurement within 2.5% at the high-density area, while AAA and PBC overestimated the dose by more than 4.5% and 4.0%, respectively. Furthermore, 15 IMRT plans, calculated using AXB, for oropharyngeal, hypopharyngeal, and laryngeal carcinomas were analyzed. The dose prescription was 70 Gy to 50% of the planning target volume (PTV70). Subsequently, each plan was recalculated using AAA and PBC while maintaining the AXB-calculated monitor units, leaf motion, and beam arrangement. Additionally, nine hypopharyngeal and laryngeal cancer patients were analyzed in terms of PTV70 for cartilaginous structures (PTV(70_cartilage)). The doses covering 50% to PTV70 calculated by AAA and PBC were 2.1% ± 1.0% and 3.7% ± 0.8% significantly higher than those using AXB, respectively (p < 0.01). The increases in doses to PTV(70_cartilage) calculated by AAA and PBC relative to AXB were 3.9% and 5.3% on average, respectively, and were relatively greater than those in the entire PTV70. AXB was found to be in better agreement with measurement in phantoms in heterogeneous areas for the 4 MV photon beam. Considering AXB as the standard, AAA and PBC overestimated the IMRT dose for head and neck cancer. The dosimetric differences should not be ignored, particularly with cartilaginous structures in PTV.

Improvement of registration accuracy in accelerated partial breast irradiation using the point-based rigid-body registration algorithm for patients with implanted fiducial markers.

PURPOSE: To investigate image-registration errors when using fiducial markers with a manual method and the point-based rigid-body registration (PRBR) algorithm in accelerated partial breast irradiation (APBI) patients, with accompanying fiducial deviations. METHODS: Twenty-two consecutive patients were enrolled in a prospective trial examining 10-fraction APBI. Titanium clips were implanted intraoperatively around the seroma in all patients. For image-registration, the positions of the clips in daily kV x-ray images were matched to those in the planning digitally reconstructed radiographs. Fiducial and gravity registration errors (FREs and GREs, respectively), representing resulting misalignments of the edge and center of the target, respectively, were compared between the manual and algorithm-based methods. RESULTS: In total, 218 fractions were evaluated. Although the mean FRE/GRE values for the manual and algorithm-based methods were within 3 mm (2.3/1.7 and 1.3/0.4 mm, respectively), the percentages of fractions where FRE/GRE exceeded 3 mm using the manual and algorithm-based methods were 18.8%/7.3% and 0%/0%, respectively. Manual registration resulted in 18.6% of patients with fractions of FRE/GRE exceeding 5 mm. The patients with larger clip deviation had significantly more fractions showing large FRE/GRE using manual registration. CONCLUSIONS: For image-registration using fiducial markers in APBI, the manual registration results in more fractions with considerable registration error due to loss of fiducial objectivity resulting from their deviation. The authors recommend the PRBR algorithm as a safe and effective strategy for accurate, image-guided registration and PTV margin reduction.

Effect of smoking prevention education using improved tobacco smoke collection method.

OBJECTIVE: To verify the effect of smoking prevention education for nursing students using the improved tobacco smoke collection method. METHODS: The improved tobacco smoke collection method allows mainstream smoke and sidestream smoke from a cigarette to be separately extracted using a closed system. After collection, we performed gas measurement using a gas detection tube and the Schiff reagent method. We provided a lecture incorporating the experimental method for an experimental group (42 students), but only the lecture without the method for a control group (43 students). We surveyed the changes in The Kano Test for Social Dependence (KTSND) scores before and after the lecture and one month later. RESULTS: In the experimental group, the total scores of the KTSND were 10.2 ± 5.0 (mean ± standard deviation) before the lecture, 5.8 ± 4.1 after the lecture, and 6.9 ± 4.8 one month later. On the other hand, the scores were 10.7 ± 5.7, 7.5 ± 5.8, and 9.7 ± 5.5 in the control group before, after, and one month after the lecture, respectively. It is considered that the students understood "smoking is harmful to health" since this gas analysis method can be used to check for harmful gases visually. CONCLUSION: Result of this study suggest that this experimental method is useful for educating nursing students on the harmful effects of smoking.

Clinical efficacy of alternating chemoradiotherapy by conformal radiotherapy combined with intracavitary brachytherapy for high-risk cervical cancer.

OBJECTIVE: The purpose of this study was to assess the outcome of alternating chemoradiotherapy in patients with high-risk cervical cancer. METHODS: We performed definitive alternating chemoradiotherapy in cervical cancer patients with at least one high-risk factor such as International Federation of Gynecology and Obstetrics III or IVA disease, primary tumor diameter ≥50 mm, positive pelvic node, and positive para-aortic node. Our chemoradiotherapy protocol was as follows: (i) alternating chemoradiotherapy with 5-fluorouracil and nedaplatin; (ii) whole pelvic radiotherapy with the dynamic conformal technique combined with intracavitary brachytherapy; (iii) prophylactic irradiation to the para-aortic region for International Federation of Gynecology and Obstetrics III/IVA or positive pelvic node and full-dose radiotherapy for positive para-aortic node. Between 1998 and 2010, 121 patients were treated with this protocol. RESULTS: The median follow-up period was 53.7 months (7.6-162.2). International Federation of Gynecology and Obstetrics stages were IB; (9.1%), IIA; 6 (5.0%), IIB; 53 (43.8%), IIIA; 7 (5.8%), IIIB; 37 (30.6%) and IVA; 7 (5.8%), respectively. Nodal involvement was reported in 77 patients (63.6%) at the pelvis and 25 (20.7%) at the para-aortic region. The 5-year overall survival and progression-free survival rates were 80.0 and 63.4%, respectively. Regarding Grade ≥3 late toxicities, three patients developed urinary and three developed intestinal toxicities. We encountered no treatment-related death. CONCLUSIONS: The clinical results of our alternating chemoradiotherapy protocol for high-risk cervical cancer are promising.

Gastric lavage guided by ultrathin transnasal esophagogastroduodenoscopy in a life-threatening case of tobacco extract poisoning: a case report.

Nicotine, which is found in tobacco, is one of the most toxic of all known poisons. A 31-year-old woman was brought to our emergency department 2 hours after ingesting a usually fatal dose of a tobacco extract. Although gastric lavage was once commonly used to treat poisoning cases of this type, lavage can lead to such complications as aspiration, hypoxia, oropharyngeal and gastric trauma, and electrolyte disturbances. Recent guidelines have suggested less-aggressive gastric-emptying procedures as initial treatments. Currently, there are no absolute indications for gastric lavage use. The present patient had a history of depressive episodes and had attempted suicide by ingesting an extract derived from 20 cigarettes mixed with alcohol. There was no evidence of vomiting or seizures occurring before arrival of the ambulance. Physical examination revealed no signs of sweating, although the patient appeared to be confused, which is often seen with nicotine intoxication. She admitted using 2 kinds of cigarette, each of which typically contain 11.2 mg of nicotine. The patient's nicotine level was suspected to be higher than 40 to 60 mg, which is normally fatal. To determine whether gastric lavage was indicated in this case, we performed ultrathin transnasal esophagogastroduodenoscopy, which neither requires sedation nor compromises the airways. Although 2 hours had passed since ingestion, the tobacco extract and food were directly visualized within the stomach. Subsequently, gastric lavage was performed with 2,000 mL of water administered through a nasogastric tube. Ultrathin esophagogastroduodenoscopy made it possible to directly observe the gastric lavage and to ensure the stomach contents had been completely removed. No changes were noted in the vital signs, and no obstruction of the airways was observed. The patient recovered quickly and was discharged the following day. Ultrathin esophagogastroduodenoscopy helped determine the diagnosis and ensure that gastric lavage had been performed without complications.